What Do Clinicians Mean by “Good Clinical Judgment”: A Qualitative Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Qualitative Approach and Research Paradigm
2.2. Researcher Characteristics
2.3. Setting
2.4. Sampling Strategy
2.5. Data Collection, Processing, and Analysis Methods
2.6. Qualitative Rigor
2.7. Ethics
3. Results
3.1. Interviewee Characteristics
3.2. Identified Themes
3.2.1. Baseline Knowledge and Adequate Clinical Experience
“I think it actually begins with knowledge. A person has to be knowledgeable, and you have to actually understand as well as you can, physiology and pharmacology. So, it really begins with knowledge. Ah, they have to have the clinical exposure, because… Things don’t present in classical sense all the time. They have to be on their own, so they can make mistakes, recognize them, and correct them because, that contributes to the overall experience.”(P4)
“I’ve seen people who, they know lots of stuff and they know all the guidelines and they know all the algorithms, and they know all the rules, and if they don’t, they can look it up in two in a half, seconds. But they don’t have the skills, they can’t bring to bear some of the other factors.”(P14)
3.2.2. Curiosity, Reflection, and Wisdom
“For the cases they were initially stumped, what I found was a key feature was curiosity. And a sense of the current conceptualization of the diagnosis was insufficient or incorrect […] curiosity drove them to find more and more information in support of the diagnosis.”(P10)
“This particular clinician was able to make very big decisions… while understanding that there is perhaps uncertainty in the case… she was able to give the impression that she was acknowledging all that while at the same time proceeding forward and making decisions.”(P1)
3.2.3. Attending to Contextual Factors and the “Bigger Picture”
“Like here was a particular professionalism issue … or a communication issue that was more nuanced because, you actually had … an angry family. Or there was splitting in the team dynamic.”(P8)
- (a)
- Prioritization
“Maybe part of the challenge and what constitutes expertise is knowing when to apply principle. It’s almost a degree of emphasis that comes with experience but other skills as well. So, we can always say in an abstract way you want to do no harm. Or you want to respect the patient’s wishes. Or you want to apply best evidence. Like there’s all of these principles that one could say are applicable, in almost every case in the assessment of good clinical judgement. However, it’s the notion of, can you successfully prioritize these things?”(P8)
- (b)
- Flexibility
- (c)
- Knowing when to “break the rules”
“They are able to tell me, ‘Yes I know what the guidelines say, but in this patient, for this reason, I’m doing this.’ And if they can give me a good reason, why they did something differently, I kind of get comfortable in their judgement because they’re telling me, ‘I know the evidence.’”(P3)
3.2.4. Good Clinical Judgment: Innate, Learned, or Both?
“I used to think that decision making was difficult to learn and difficult to teach… I thought people innately had it or they didn’t… it’s like common sense… but we have this trainee right now who’s clinical decision making was relatively poor six months ago and he changed my mind… he’s worked hard to build those building blocks of knowledge and experience; he has learned to listen to patients… to actually being a reasonable decision maker.”(P4)
- (a)
- Break down where the judgment is “going wrong”
“Sometimes, what’s perceived as a judgement is, for example, anxiety. People with anxiety disorders will often not be able to close their history taking… they just keep gathering, and gathering because, they are so afraid that they’re going to miss something… if we are going to teach learners the first thing to be able to do, is figure out what their learning needs are and if this person has, doesn’t have good clinical judgement that’s a very sweeping term. We better figure out what it may possibly be.”(P14)
- (b)
- Opportunities for modelling
“I think the idea that sometimes cases are unclear and being upfront about your rationale with trainees about why you are doing what you are doing and acknowledging the fact that you might be wrong and that its okay to be wrong. But you have to have a justification for what you’re, why you are doing it and then re-evaluation of that as new data becomes available.”(P1)
4. Discussion
4.1. Limitations of Study
4.2. Summary and Future Directions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A
Preamble: This Interview Is Meant to Be Informal and Is Aimed at Helping us Understand the Concept of Clinical Judgment and How It can Be Assessed. The First Part of the Interview will Consist of Questions Aimed at Understanding Your Definition of Clinical Judgment and How You have Observed It in the Past. The Second Part will Consist of Questions Aimed at How you Think We Should Assess Clinical Judgment and the Third Part will Consist of Questions Intended to Determine How You would Use Such Assessments in a Practical Way. | |
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Question | Notes |
Can you state your name, the date, your educational background, your experience in clinical practice and your experience with education and trainees? | |
Can you think of another clinician or mentor that you have looked up to that displayed good clinical judgement? What was it about what elements of good judgment do you think you learned from them? Can you think of examples? | |
Can you give an example of an instance when a trainee has had challenges with their judgement or decision making? | |
What does good clinical judgment mean to you? | |
(Show interviewee the following) The Association of Faculties of Medicine of Canada (AFMC) defines the Entrustable Professional Activities (EPA) or management decisions as “purposes evidence informed holistic management plans that include pharmacologic and non-pharmacologic components developed with an understanding of the patients’ context, values and illness experience, considers priorities and other health care professions advice” What do you think of this EPA? Are there elements that you could identify good judgment with | |
Are there environmental factors that you think may affect trainee clinical judgement? | |
What elements do you think are essential to clinical judgement? Do you think good judgment is about knowledge or is it an innate quality? If it is the latter, can it be learned and how can we teach it? | |
If a management decision is assessed to have deficits in judgement, can you usually identify one or two contributing issues for feedback? | |
How does your assessment of a trainee’s clinical judgement affect your supervision of that trainee? | |
If you were to provide descriptors to an instance of poor, satisfactory and exemplary clinical judgment, what would they be |
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Stage of Career | Expert Domain | Sex | Educational Involvement |
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Early (1–5 years) = 3 Mid (6–20 years) = 9 Late (>20 years) = 2 Retired = 2 | Emergency Medicine = 3 Family Medicine = 1 Medicine = 6 Psychiatry = 1 Pediatrics = 1 Geriatrics = 1 Surgery = 3 | Male = 10 Female = 6 | Clinician educators = 16 |
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Tsang, M.; Martin, L.; Blissett, S.; Gauthier, S.; Ahmed, Z.; Muhammed, D.; Sibbald, M. What Do Clinicians Mean by “Good Clinical Judgment”: A Qualitative Study. Int. Med. Educ. 2023, 2, 1-10. https://doi.org/10.3390/ime2010001
Tsang M, Martin L, Blissett S, Gauthier S, Ahmed Z, Muhammed D, Sibbald M. What Do Clinicians Mean by “Good Clinical Judgment”: A Qualitative Study. International Medical Education. 2023; 2(1):1-10. https://doi.org/10.3390/ime2010001
Chicago/Turabian StyleTsang, Michael, Leslie Martin, Sarah Blissett, Stephen Gauthier, Zeeshan Ahmed, Deeqo Muhammed, and Matthew Sibbald. 2023. "What Do Clinicians Mean by “Good Clinical Judgment”: A Qualitative Study" International Medical Education 2, no. 1: 1-10. https://doi.org/10.3390/ime2010001